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The Permanent Working Group of European Junior Hospital Doctors (PWG) represents the interests, in international matters, of trainees from 23 member states. The PWG recognizes the importance of postgraduate training (PGT) in the maintenance of high quality health care delivery, and in this paper presents its current policy on PGT. This replaces its policy previously published in Medical Education 1989, 23, 339-47. The paper examines the context within which PGT occurs, and calls for an urgent review of its provision and funding. Basic principles, such as PGT existing within a continuum of medical education and the application of a quality assurance-based model, underpin the development of later sections on the structure, process and outcomes of PGT. These recommend the establishment of structured training programmes which should incorporate modern educational practice in the provision and monitoring of PGT. Emphasis is placed on the opportunities for training in the clinical setting and the utilization of a range of educational techniques. Evaluation and guidance by and of clinical supervisors and designated trainers is linked with the responsibilities of the trainee, and is placed within the context of a system of accountability, thus closing the quality assurance cycle. It is recommended that the views of the consumers of PGT, the trainees, are more fully considered in the development of training programmes. Finally, the potential for further harmonization is considered, with cautious advances being proposed.

Context: Health advocacy is an essential component of postgraduate medical education, and is part of many physician competency frameworks such as the Canadian Medical Education Directives for Specialists (CanMEDS) roles. There is little consensus about how advocacy should be taught and assessed in the postgraduate context. There are no consolidated guides to assist in the design and implementation of postgraduate health advocacy curricula., Objectives: This scoping review aims to identify and analyse existing literature pertaining to health advocacy education and assessment in postgraduate medicine. We specifically sought to summarise themes from the literature that may be useful to medical educators to inform further health advocacy curriculum interventions., Methods: MEDLINE, Embase and ERIC were searched using MeSH (medical student headings) and non-MeSH search terms. Additional articles were found using forward snowballing. The grey literature search included Google and relevant stakeholder websites, regulatory bodies, physician associations, government agencies and academic institutions. We followed a stepwise scoping review methodology, followed by thematic analysis using an inductive approach., Results: Of the 123 documents reviewed in full, five major themes emerged: (i) conceptions of health advocacy have evolved towards advocating with rather than for patients, communities and populations; (ii) longitudinal curricula were less common but appeared the most promising, often linked to scholarly or policy objectives; (iii) hands-on, immersive opportunities build competence and confidence; (iv) community-identified needs and partnerships are increasingly considered in designing curriculum, and (v) resident-led and motivated programmes appear to engage residents and allow for achievement of stated outcomes. There remain significant challenges to assessment of health advocacy competencies, and assessment tools for macro-level health advocacy were notably absent., Conclusions: There is considerable heterogeneity in the way health advocacy is taught, assessed and incorporated into postgraduate curricula across programmes and disciplines. We consolidated recommendations from the literature to inform further health advocacy curriculum design, implementation and assessment., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Objectives/hypothesis: Optimizing value of medical service trips (MSTs) requires alignment of the services provided with the needs and desires of hosts. Our aim was to understand which MST services Vietnamese otolaryngologists find most beneficial and contrast to those believed most important by volunteers., Study Design: Cross-sectional survey., Methods: Otolaryngologists from a tertiary care institution travel to Vietnam yearly. In March 2018, surveys were distributed to Vietnamese otolaryngology faculty, residents, and US otolaryngology volunteers. The value of 11 MST-provided services were graded on a five-point Likert scale. Services included observing US otolaryngology volunteers perform surgery, US otolaryngology volunteer lectures, paper/electronic lecture material, instrument donation, minifellowships in the United States, among others. Respondents also voted for the single most important service. Responses were analyzed via Kruskal-Wallis analysis of variance and Wilcoxon rank sum test., Results: A total of 153 survey responses were recorded. There were 52% respondents who identified as male and 39% as female. The highest-valued services by Vietnamese otolaryngologists were didactic lectures given by US otolaryngology volunteers (4.6/5 ± 0.6), and reviewing cases with US otolaryngology volunteers in the clinic (4.4/5 ± 0.9). The least important services were instrument donation and seeing US otolaryngology volunteers assist with surgery (≤4.1/5). The highest-value services perceived by US otolaryngology volunteers were reviewing cases in the clinic and sponsoring minifellowships (4.9 ± 0.4). Vietnamese faculty perceived the single most important service to be US volunteer lectures (20/74 votes), whereas Vietnamese residents perceived minifellowships to be most important (13/34 votes) CONCLUSIONS: Vietnamese otolaryngologists desire an education-focused relationship with US otolaryngology volunteers, with didactic lectures and sponsored US fellowships having the highest value and performance of surgeries having less value., Level of Evidence: 4 Laryngoscope, 130:E305-E310, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: The educational alliance is argued to be at the heart of supervision in medical education. This review aims to map the research field and develop a conceptualisation of the nature of such educational alliances within postgraduate supervision for general practitioners., Methods: An integrative review of the international literature on supervision from 2011 to 2018 was undertaken, and papers assessed for relevance and quality. Data analysis incorporated framework analysis techniques. Bordin's working alliance-based model of supervision was used as a springboard for synthesis, as well as allowing for the emergence of new ideas, theories and concepts from the literature., Results: A total of 49 full texts were included for analysis. There was evidence of the importance of trust, agreement and bond in accordance with Bordin's model. The results also highlighted the importance of greater clarity on supervisory goals, and the tasks to support these goals, to effectively address competing priorities and roles within supervision. Non-hierarchical relationships were advocated, although supervisors must remain impartial in their assessment and monitoring roles. The influence of the wider practice community and situated learning through legitimate peripheral participation are documented. A model of General practice (GP) supervision is proposed that integrates the findings., Conclusions: GP supervision requires a greater emphasis than is suggested by the working alliance model, both on the clarity of expectations and the appreciation of the multiple roles and competing priorities of both trainee and supervisor. Furthermore, as GP supervision develops within the rising workload of contemporary general practice, the role of the wider community of practice may become more prominent. We have adapted the working alliance model for postgraduate General practice (GP) supervision, emphasising the explicit sharing of expectations relating to goals, tasks and roles to facilitate negotiation and agreement., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Objectives: This paper reviews why tensions between service and education persist and highlights that this is an area of medical education research (MER) that, to date, lacks a robust body of theory-driven research. After carrying out a review of the literature on service-education tensions in medical education and training, we turn to consider how theory can help provide new insights into service-education tensions., Methods: We conducted a search of the literature on service-education tensions since 1998 to examine the use of theory in studies on this topic., Results: We identified 44 out of 603 relevant papers. Their focus fell into four broad categories: time residents spent on 'service' and 'education'; perceptions of the balance between service and education; considerations of how best to define service and education, and the impact of structural and systems changes on education/training. Of the papers reporting primary research, the dominant methodology was the bespoke survey. Rarely were the precise natures of tensions or how different factors interact to cause tensions examined in detail., Discussion: Through discussion and reflection, we then agreed on the applicability of four sociocultural theories for illuminating some examples of service-education tensions. We present four sociocultural theories: Holland's figured worlds, Kemmis et al.'s practice architectures, Lave and Wenger's situated learning and Engeström's cultural-historical activity theory (CHAT or AT). We describe each and then briefly illustrate how each theory can support new ways of thinking and potential directions for research focusing on education-service tensions., Conclusions: The use of theory in research studies will not resolve service-education tensions. However, what theory can do is illuminate and magnify different aspects of service-education tensions, to generate new insight and knowledge that can then be used to inform future research and changes in practice., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Patients are increasingly being engaged in providing feedback and consultation to health care institutions, and in the training of health care professionals. Such involvement has the potential to disrupt traditional doctor-patient power dynamics in significant ways that have not been theorised in the medical literature. Critical theories can help us understand how power flows when patients are engaged in the training of medical students., Methods: This paper applies postcolonial theory to the involvement of patients in the development and delivery of medical education. First, I review and summarise the literature around patient involvement in medical education. Subsequently, I highlight how postcolonial frameworks have been applied to medical education more broadly, extrapolating from the literature to apply a postcolonial lens to the area of patient engagement in medical education., Conclusion: Concepts from postcolonial theory can help medical educators think differently about how patients can be engaged in the medical education project in ways that are meaningful and non-tokenistic. Specifically, the positioning of the patient as 'subaltern' can provide channels of resistance against traditional power asymmetries. This has curricular and methodological implications for medical education research in the area of patient engagement., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: The Accreditation Council for Graduate Medical Education (ACGME) Milestone Project mandates programmes to assess the attainment of training outcomes, including the psychomotor (surgical or procedural) skills of medical trainees. The objectives of this study were to determine which tools exist to directly assess psychomotor skills in medical trainees on live patients and to identify the data indicating their psychometric and edumetric properties., Methods: An electronic search was conducted for papers published from January 1948 to May 2011 using the PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science electronic databases and the review of references in article bibliographies. A study was included if it described a tool or instrument designed for the direct observation of psychomotor skills in patient care settings by supervisors. Studies were excluded if they referred to tools that assessed only clinical or non-technical skills, involved non-medical health professionals, or assessed skills performed on a simulator. Overall, 4114 citations were screened, 168 (4.1%) articles were reviewed for eligibility and 51 (1.2%) manuscripts were identified as meeting the study inclusion criteria. Three authors abstracted and reviewed studies using a standardised form for the presence of key psychometric and edumetric elements as per ACGME and American Psychological Association (APA) recommendations, and also assigned an overall grade based on the ACGME Committee on Educational Outcome Assessment grading system., Results: A total of 30 tools were identified. Construct validity based on associations between scores and training level was identified in 24 tools, internal consistency in 14, test-retest reliability in five and inter-rater reliability in 20. The modification of attitudes, knowledge or skills was reported using five tools. The seven-item Global Rating Scale and the Procedure-Based Assessment received an overall Class 1 ACGME grade and are recommended based on Level A ACGME evidence., Conclusions: Numerous tools are available for the assessment of psychomotor skills in medical trainees, but evidence supporting their psychometric and edumetric properties is limited., (© 2013 John Wiley & Sons Ltd.)

Aim: This aim of this paper was to explore new doctors' preparedness for prescribing., Methods: This was a multiple methods study including face-to-face and telephone interviews, questionnaires and secondary data from a safe prescribing assessment (n= 284). Three medical schools with differing curricula and cohorts were included: Newcastle (systems-based, integrated curriculum); Warwick (graduate entry) and Glasgow [problem-based learning (PBL)], with graduates entering F1 in their local deanery. The primary sample consisted of final year medical students, stratified by academic quartile (n= 65) from each of the three UK medical schools. In addition an anonymous cohort questionnaire was distributed at each site (n= 480), triangulating interviews were conducted with 92 clinicians and questionnaire data were collected from 80 clinicians who had worked with F1s., Results: Data from the primary sample and cohort data highlighted that graduates entering F1 felt under-prepared for prescribing. However there was improvement over the F1 year through practical experience and support. Triangulating data reinforced the primary sample findings. Participants reported that learning in an applied setting would be helpful and increase confidence in prescribing. No clear differences were found in preparedness to prescribe between graduates of the three medical schools., Conclusion: The results form part of a larger study 'Are medical graduates fully prepared for practice?'. Prescribing was found to be the weakest area of practice in all sources of data. There is a need for more applied learning to develop skill-based, applied aspects of prescribing which would help to improve preparedness for prescribing., (© 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.)

Context: A particularly onerous aspect of the transition from medical student to practising doctor concerns the necessity to be able to rapidly identify acutely unwell patients and initiate appropriate resuscitation. These are skills in which many graduates feel poorly prepared and are considered by some to be best learned on the job. This constructivist study investigated the factors that influence the behaviour of junior doctors in this context and initiated the development of a framework that promotes understanding of this important area., Methods: Focus groups involving 36 clinicians with a variety of clinical experience were conducted and analysed using a qualitative, grounded theory approach. The complex relationships between emergent themes guided the development of a framework that was refined and validated by further interviews with participants., Results: Six main themes, grouped under three broad headings, emerged from the data: 'transferring knowledge into practice' and 'decision making and uncertainty' (cognitive challenges); 'acts and omissions' and 'identity and expectations' (roles and responsibilities), and, finally, 'the medical hierarchy' and 'performing under stress' (environmental factors). The framework presented within this paper illustrates the complex relationships between these factors., Conclusions: Although the potential of metacognitive strategies to reduce medical error is acknowledged, the framework promotes looking beyond the individual to consider the contributions to patient safety of identity issues, role uncertainty and the hierarchical clinical environment. A more distributed approach to situation awareness may help junior doctors to better tolerate complexity and uncertainty. The efficacy of simulation as an educational strategy may be improved by finding ways to recreate the hierarchical and stressful environment in which junior doctors practise. Junior doctors should be aware of the impact of affect and emotion on behaviour, and clinical supervisors should strive to ensure that roles and responsibilities are explicitly discussed., (© Blackwell Publishing Ltd 2011.)

Objectives: The alleged medical education continuum is interrupted by a number of major transitions. After starting medical school, the first transition students encounter is that from non-clinical to clinical training. The second transition is that of graduated student to junior doctor or specialist trainee, and the third concerns the specialist trainee's transition to medical specialist. As a first step towards a better understanding of the effects of transitions, this paper provides a critical overview of how these transitions have been conceptualised in the medical education domain. The findings are complemented with perspectives from the fields of transitional psychology and organisational socialisation. The transition into medical school is not reviewed., Methods: Using the term 'transition', six leading medical education journals were searched for relevant articles. A snowballing technique on the reference lists of the 44 relevant articles yielded 29 additional publications. Studies were reviewed and categorised as representing objectifying, clarifying, or descriptive and/or justifying research., Results: When students enter clinical training, they need to relearn what they thought they knew and they must learn new things in a more self-directed way. As junior doctors or specialist trainees, their main challenges involve handling the many responsibilities that accompany the delivery of patient care while simultaneously learning from the process of providing that care. As medical specialists, new non-medical tasks and decisions on how to delegate responsibilities become issues., Conclusions: Research on transitions has objectified the challenges students and doctors face. Clarifying studies often lack conceptual frameworks that could help us to gain deeper insight into the observed phenomena. Psychology offers valuable theoretical perspectives that are applicable to medical education transitions. To transform a transition from a threat to a learning opportunity, medical education should assist students and doctors in developing the coping skills they need to effectively deal with the challenges presented by new environments., (© Blackwell Publishing Ltd 2010.)

Context: Trainees in undergraduate and postgraduate medical education engage in multiple transitions as part of the educational process, including many transitions that occur on both periodic and daily bases within medical education programmes. The clinical rotation, based on either a medical discipline or clinical care setting and occurring over a predetermined, short period of time, is a deeply entrenched educational approach with its roots in Abraham Flexner's seminal report. Many assumptions about the presumed benefits of clinical rotations have become pervasive despite a lack of empirical evidence on their optimal timing and structure, and on how transitions between clinical rotations should occur., Methods: In this paper, we examine the issue of rotational transitions from the three perspectives of sociology, learning theory, and the improvement of quality and safety., Results: Discussion from the sociological perspective addresses the need for much greater attention to interprofessional relationships and professional development, whereas that from the learning theory perspective examines the gap between what is known from pedagogical and cognitive science and what is currently practised (learning theory). Discussion from the perspective of improving quality and safety refers to the critical need to embed trainees in functional clinical microsystems as meaningful participants., Conclusions: Research is urgently needed on the effects of transitions on trainees, faculty staff, non-doctor health care providers and patients in order to optimise future competency-based training models and confirm or refute current assumptions., (© Blackwell Publishing Ltd 2010.)

Background: Training of healthcare workers can play an important role in improving quality of care, and reducing maternal and perinatal mortality and morbidity., Objectives: To assess the effectiveness of training programmes aimed at improving emergency obstetric care in low-resource environments., Search Strategy: We searched Pubmed, Embase, Popline and selected websites, and manually searched bibliographies of selected articles. Language was not an exclusion criterion., Selection Criteria: All papers describing postgraduate training programmes aimed at improving emergency obstetric care in low-resource environments were included., Data Collection and Analysis: Two reviewers independently extracted the data and classified these according to the level of the measured effects (reaction of participants, improved knowledge and skills, changes in behaviour and outcomes in practice). Any disagreements were resolved by discussion with a third author until agreement was reached., Main Results: A total of 38 papers were selected. Training programmes vary considerably in length, content and design. The evaluation of effects is often hampered by inadequate study design and the use of non-validated measuring instruments. Most papers describe positive reactions, increased knowledge and skills, and improved behaviour after training. Outcome is assessed less frequently, and positive effects are not always demonstrated. Measures that can contribute to a positive effect of training programmes include hands-on practise, team approaches and follow-up on training efforts., Author's Conclusions: Training programmes may improve quality of care, but strong evidence is lacking. Policymakers need to include evaluation and reporting of effects in project budgets for new training programmes.

Context: The white paper 'Trust, Assurance and Safety: the Regulation of Health Professionals in the 21st Century' proposes a single, generic multi-source feedback (MSF) instrument in the UK. Multi-source feedback was proposed as part of the assessment programme for Year 1 specialty training in histopathology., Methods: An existing instrument was modified following blueprinting against the histopathology curriculum to establish content validity. Trainees were also assessed using an objective structured practical examination (OSPE). Factor analysis and correlation between trainees' OSPE performance and the MSF were used to explore validity. All 92 trainees participated and the assessor response rate was 93%. Reliability was acceptable with eight assessors (95% confidence interval 0.38). Factor analysis revealed two factors: 'generic' and 'histopathology'. Pearson correlation of MSF scores with OSPE performances was 0.48 (P = 0.001) and the histopathology factor correlated more highly (histopathology r = 0.54, generic r = 0.42; t = - 2.76, d.f. = 89, P < 0.01). Trainees scored least highly in relation to ability to use histopathology to solve clinical problems (mean = 4.39) and provision of good reports (mean = 4.39). Three of six doctors whose means were < 4.0 received free text comments about report writing. There were 83 forms with aggregate scores of < 4. Of these, 19.2% included comments about report writing., Results: Specialty-specific MSF is feasible and achieves satisfactory reliability. The higher correlation of the 'histopathology' factor with the OSPE supports validity. This paper highlights the importance of validating an MSF instrument within the specialty-specific context as, in addition to assuring content validity, the PATH-SPRAT (Histopathology-Sheffield Peer Review Assessment Tool) also demonstrates the potential to inform training as part of a quality improvement model.

Context: This paper examines the criterion validity of the Graduate Medical School Admissions Test (GAMSAT), which has been used since 1996 in Australia and more recently in the UK and Ireland. The study provides evidence on the extent to which GAMSAT, in combination with grade point average (GPA) and interview scores, adds value to determining an individual's capability for medical study. The study responds to increasing demand for information on the validity of selection processes. Criterion validity is important because it helps to empirically situate selection tests within their broader contexts by, for instance, providing an assurance to educators and the public that test results are valid and add value to selection decisions., Methods: After introducing the rationale and focus of the study, the paper summarises the data and research methods, presents statistical results and draws conclusions that advance current insight into medical school admissions processes. The results are based on data from six institutions and 351 students., Results: Analyses of GAMSAT, interview and GPA scores show, in summary, that: there are fairly high levels of divergence between these three measures; that relationships between the measures and Year 1 marks vary across institutions, and that a combination of GAMSAT and GPA scores provides the best means of predicting Year 1 performance.

Objectives: This study set out to answer the following questions. What influences a junior doctor's response to a judgement call within a clinical setting? What, if any, are the relationships between these influences?, Methods: This paper describes an interpretivist study based on a grounded theory approach to data analysis. This involved a phased approach to data collection using semi-structured interviews. Analysis was facilitated by observations and group presentations. Participants were doctors in their first year of postgraduate practice who were purposively selected from a range of hospitals in the Northern Deanery., Results: The data demonstrated a number of influences on whether junior doctors chose to seek senior assistance. These included the upholding and balancing of tenets that were necessary for ensuring safe practice, and estimating the chance and severity of potential negative consequences to patients, themselves and their teams. In order to make these judgements, junior doctors drew on different forms of knowledge, especially knowledge gained from previous clinical experiences. In judging whether or not to contact a senior, pre-registration house officers (PRHOs) were practising essential clinical attributes, that of independent yet co-operative and discerning practitioners who are able to balance multiple considerations while ensuring patient care., Conclusions: This particular judgement of risk, as it was described by those interviewed, was a dynamic process exemplified by the need to create counterbalances between multiple consequences. As a result, no prescriptive action could have allowed PRHOs to deal with the numerous configurations they faced and took into account.

Background: A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learner's evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualize a dynamic awareness of prevailing risk and the implications of moving between zones., The Importance of Context: We argue that clinical exposure can be consolidated by simulation where appropriate, ensuring that each learner gains the skills for safe care within the increasingly limited time available for training. To be effective, however, such simulation must be realistic, patient-focused, structured and grounded in an authentic clinical context. Challenge comes not only from technical difficulty but also from the need for interpersonal skills and professionalism within clinical encounters., Patient Focused Simulation: Many existing simulations focus on crises, so clinicians are in a heightened state of expectation that may not reflect their usual practice. We argue that simulation should also reflect commonly occurring non-crisis situations, allowing clinicians to develop an awareness of the complex events that underpin clinical encounters. We describe a patient-focused approach to simulation, using simulated patients and inanimate models within realistic scenarios, to ground experience in authentic clinical practice and bring together the complex elements that underpin clinical events., Applications: Although our argument has evolved from surgical practice and operating theatre teams, we believe it can be widely applied to the increasing number of health care professionals who perform clinical interventions.

Context: The last 10 years have represented a period of significant reform within both the health care and education systems in France. In terms of its workforce, France faces a shortage of doctors, particularly in primary care., Methods: This paper examines the French medical curriculum, student selection, licensure and continuing medical education and discusses the challenges currently facing French medical faculties., Results: The French medical curriculum is defined nationally, with methods adapted at medical school level. There has been some uptake of innovative methods such as problem-based learning, skills-based teaching and performance-based assessment. However, traditional didactic teaching of scientific medicine and the apprenticeship model remain dominant. France uses a unique method of selection, which is the subject of much debate. Following a general year, medical students are subject to a selection examination that permits only a small number to continue studies. Similarly, at the end of medical school, a written test is used to rank students for the purpose of matching to specialty training. France has no national colleges or licensing authorities and thus authorisation to practise rests on the diploma delivered by each faculty of medicine. From 2005, continuing medical education became compulsory for all doctors. It includes the evaluation of medical practice., Conclusions: French faculties of medicine face several challenges, including: rising numbers of students without a commensurate growth in the number of faculty members; an increasing emphasis on multidisciplinary health care; a drive towards mandatory continuing education and performance-based outcomes, and the development of national selection examinations that are knowledge-based.

Introduction: In 1996 the University of Liverpool introduced an integrated problem-based learning (PBL) medical curriculum incorporating the recommendations of Tomorrow's Doctors. This paper investigates whether the PRHO (pre-registration house officer) educational supervisors who supervise Liverpool graduates believe that the reformed curriculum is producing house officers who have the competencies outlined by the General Medical Council., Methods: Forty-one interviews were arranged with a sample of educational supervisors in the Mersey Deanery area to ascertain their views on the competencies of Liverpool PRHOs. The interviews were tape-recorded, transcribed and analysed., Results: The supervisors felt that the PRHOs had been well prepared to work as PRHOs, and compared with traditional graduates they were actually better prepared for the job of PRHO. They saw the PRHOs as competent communicators with improved clinical skills, who had good attitudes, were aware of limitations, were team workers, good at history-taking and examination and had different approaches to finding information. There was a very confusing picture regarding basic knowledge, with some consultants expressing concerns, despite saying they had adequate knowledge to work as PRHOs. It emerged that there was little consensus about the knowledge base of the traditional or PBL graduates or what knowledge level was needed at this stage., Discussion: Educational supervisors believe that the reformed curriculum in Liverpool is producing competent PRHOs who have been better prepared for the role of PRHO than previous graduates. It could be that uncertainty over knowledge base may be the price paid for reducing the factual burden and improving preparedness for professional practice.

Background: Doctors' interpersonal and communication skills correlate with improved health care outcomes. International medical organisations require competency in communication skills. The Accreditation Council for Graduate Medical Education (ACGME) developed a toolbox for assessing this competency and 5 others, yet none initially for teaching these skills., Purpose and Methods: The original focus in the development of the ACGME competencies was evaluation. This paper represents a significant step toward defining methods for teaching communication skills competencies. A total of 16 medical education leaders from medical schools worldwide, participating in the 2003 Harvard Macy Institute Program for Physician Educators, worked together to: (1) further define the ACGME competency in interpersonal and communication skills; (2) delineate teaching strategies for each level of medical education; and (3) create a teaching toolbox to integrate communication skills competencies into medical curricula. Four subgroups defined subcompetencies, identified teaching strategies for undergraduate, graduate and postgraduate medical training and brought their work to the larger group. The expanded communication competencies and teaching strategies were determined by a consensus of the larger group, presented to 80 Harvard Macy Scholars and Faculty for further discussion, then finalised by consensus., Conclusion: The teaching toolbox expands the ACGME core communication competencies, adds 20 subcompetencies and connects these competencies to teaching strategies at each level of medical training. It represents the collaboration and consensus of a diverse international group of medical education leaders in a variety of medical specialities and institutions, all involved in teaching communication skills. The toolbox is applicable globally across different settings and specialities, and is sensitive to different definitions of health care.

Aims: This paper describes the process of validating the Readiness for Interprofessional Learning Scale (RIPLS) for use with postgraduate health care professionals., Context: The RIPLS questionnaire has proved useful in the undergraduate context, enabling tutors to assess the readiness of students to engage in interprofessional learning (IPL). With the drive in the National Health Service (NHS) to deliver health care in interprofessional teams, it seems logical to ask whether postgraduate education should, or could, be delivered successfully in interprofessional contexts. As a preliminary to undertaking an extended IPL project, the researchers tested the validity of the RIPLS tool in the postgraduate health care context., Method: A modified version of the RIPLS questionnaire was administered to all general practitioners, nurses, pharmacists and allied health professionals in the Dundee Local Health Care Cooperative (LHCC) (n = 799). A total of 546 staff responded (68%)., Results: Three factors, comprising 23 statements, emerged from the statistical analysis of the survey data, namely, teamwork and collaboration, sense of professional identity and patient-centredness. The internal consistency measure was 0.76. Analysis of variance suggested some key differences between the different professions in respect of the factors., Conclusions: The RIPLS questionnaire was validated for use in the postgraduate context, thus providing researchers with a tool for assessing health professionals' attitudes towards interprofessional learning at practice level, community health partnership level or at a national level of education and training. Significant differences between professional groups should be taken into account in designing any interprofessional learning programme.

Background: The continued reduction in junior doctors' hours in the UK has made it necessary to re-examine traditional assumptions about the synonymous natures of training and service. This paper researches senior house officers' (SHOs) perceptions of 'service' and 'training', with reference to where they place activities along the training/service continuum, and the factors that lead them to classify these activities in the way they do., Methods: Questionnaires were sent to all identified SHOs at Plymouth Hospitals NHS Trust (40% response rate). Three focus groups were held with 5 SHOs, 3 consultants and 2 clinical tutors. Quantitative data derived from the questionnaires were analysed using spss. Qualitative data collected in the focus groups was coded with the aid of n6, which facilitated the thematic analysis of transcripts., Results: Analysis of the quantitative data allowed the construction of the training/service continuum diagram. Identified factors affecting the perceived training/service balance of SHO activities included: frequency, time, type and nature of work, number of patients, supervision, interaction, other commitments, purpose and focus of the activity, the individual trainee and trainer, and experience and competence., Discussion: It is no longer appropriate to assume that all junior doctor activities represent either training or service individually: activities are perceived differently along the training/service continuum depending on their execution and their relation to the SHOs' learning curves. Within the reduced hours framework, it is necessary to match this balance to experience, in order for both training and service requirements to be satisfied.

Introduction: Career choice, sense of professional identity and career behaviour are influenced, subject to change and capable of development through interaction with the learning environment. In this paper workplace learning discourses are used to frame ongoing concerns associated with higher specialist training. Data from the first stage of a multimethods investigation into recruitment into and retention in specialties in the West Midlands is used to consider some possible effects of the specialist learning environment on recruitment and retention., Methods: The aim of the study was to identify issues, through interviews with 6 consultants and questionnaires completed by specialist registrars from specialties representing a range of recruitment levels. These would inform subsequent study of attributes and dispositions relevant to specialist practice and recruitment. The data were analysed using NVivo software for qualitative data management., Results: Participants' perceptions are presented as bipolar dimensions, associated with: curriculum structure, learning relationships, assessment of learning, and learning climate. They demonstrate ongoing struggle between different models of workplace learning., Conclusion: Changes in the postgraduate education of doctors seem set to continue well into the future. How these are reflected in the balance between workplace learning models, and how they influence doctors' sense of identity as specialists suggests a useful basis for examination of career satisfaction and recruitment to specialties.

Introduction: This paper describes the development and implementation of an educational intervention to help general practitioners (GPs) recognise young people with first episode psychosis., Method: The Medical Research Council complex interventions framework was used to guide the development of the intervention. The theoretical phase included a literature review of previous educational interventions in primary care and consideration of the literature on attitude formation and change, and the relationship between attitudes and behaviour. The modelling phase included focus groups with GPs and service users, and a training needs analysis questionnaire administered to GPs. The 2-stage intervention consisted of a video featuring role-plays of primary care consultations, GP-led discussion and discussion with early intervention service users. The acceptability and utility of the educational programme was evaluated using a 5-point Likert scale questionnaire administered at the end of each session., Results: General practitioners from each of the 39 intervention practices participated in the initial session and from 27 practices in the booster session. Information about symptoms and signs of first episode psychosis was the most valued aspect of the initial session. The booster session was also well received, with GPs valuing the opportunity to gain insight into first episode psychosis from users., Conclusions: This paper adds a pragmatic description to the literature on the development of educational interventions in primary care. The Medical Research Council framework helped to identify and clarify component parts of the intervention and how the active components may relate to the expected outcome of behaviour change.

Background: Work-based learning occupies a central role in the training and ongoing development of the medical workforce. With this arises the need to understand the processes involved, particularly those relating to informal learning. Approaches to informal learning in postgraduate medical education have tended to consider the mind as an independent processor of information., Method: In this paper, such cognitive approaches are critiqued and an alternative socio-cultural view on informal learning described. Recent and imminent changes in postgraduate medical education are identified, namely the reduction in patient experience, the fragmentation of teaching, and the development of competency frameworks and structured curricula. It is argued that although the latter may be useful in the construction of formal learning programmes, they will do little to enhance the progression of the individual from newcomer to old-timer or the cultural assimilation of the learner into a profession., Discussion: Strategies for enhancing informal learning in the workplace are recommended in which increased attention is paid to the development of the medical apprentice within a community of social practice. These include the establishment of strong goals, the use of improvised learning practices, attention to levels of individual engagement and workplace affordances, immersion in professional discourse and behaviours, support in relation to the development of a professional identity and the provision of opportunities to transform social practice.

Objective: To collate the published works on validation of assessments used in postgraduate medical certification., Design: Systematic review of original papers on reliability and validity of assessments used in medical postgraduate certification., Setting: Medical and education research databases., Results: Fifty-five papers were identified from 1985 to 2000. A wide range of approaches to validation were employed. Inter-rater reliability and internal consistency were the most reported foci for validation. There were just two papers on consequential validity, and only a few on construct validity. These two forms of validity are considered central in recent general education writing. The majority of papers were from general and family practice. There was a noticeable lack of papers from the UK Royal Colleges (except the Royal College of General Practitioners), despite 5 years of the new unified grade and the renewed emphasis on the role of the Royal Colleges in setting assessment criteria., Conclusions: There is a relative scarcity of published papers on validation of assessment for postgraduate medical certification considering the influence these high stakes processes have on doctors career progression and employment opportunities. General and family practice institutions in a number of English speaking countries have set an example to others, by showing that rigour and transparency in assessment development and implementation can be reflected in publication.

The current emphasis on providing quality undergraduate and postgraduate medical education has focused attention on the educational responsibilities of all doctors. There is a greater awareness of the need to train doctors as educators and courses have been set up to satisfy this need. Some courses, such as those on how to conduct appraisal, are specific to one task facing a medical educator. Other courses take a broader view and relate educational theory to practice. In this paper we describe an outcome-based approach in which competence in teaching is defined in terms of 12 learning outcomes. The framework provides a holistic approach to the roles of the teacher and supports the professionalism of teaching. Such a framework provides the basis for the development of a curriculum for teaching excellence. It helps to define important competences for different categories of teachers, communicate the areas to be addressed in a course, identify gaps in course provision, evaluate courses, assist in staff planning and allow individuals to assess their personal learning needs. The framework is presented to encourage wider debate.

In the past 10 years, significant developments in general practice teaching and research have led to the considerable growth of academic general practice as a discipline. This paper reviews issues relating to these developments, particularly career pathways and training aspects. The need to extend these advances to the broadening arena of primary health care has given further impetus for the development of academic careers. General practice will need to work closely with secondary care, community health, and social services to develop primary health care in its broadest sense, and an evidence base, generated by relevant research and evaluation, must underpin all of this. Structural and funding changes to undergraduate education, postgraduate training and primary care research have created a range of opportunities for general practice clinicians to define career pathways, not formerly available, within multiprofessional and multidisciplinary departments and groups. Education for future general practice and primary care must underpin developments as much as a research base. Relevant masters' degrees and diplomas are now widely available, and extended vocational training and higher professional education will enable general practitioners in their formative years to consider academic opportunities.

Context: The responsibility to determine just who is competent to practice medicine, and at what standard, is great. Whilst there is still a period available for potential remediation, examinations at the completion of year three of the four-year Graduate Entry Medical Programme (GEMP) at Flinders University of South Australia (FUSA) are high stakes and contain the majority of final summative assessment for the certification of student to doctor. Therefore, the medical school has recently examined its methods for certification, the clinical practice standards sought in its programme and how to determine these standards., Design: For all assessments a standard was documented and methods employed to set these standards using specific measures of performance. A modification of the Angoff method was applied to the written examination and the Rothman method, using two criteria, was used to determine competency in the objective structured clinical examination (OSCE). These methods were used for the first time in 1998. Both methods used trained 'experts' as standard setters and both methods used the notion of the 'borderline candidate' to determine the passing standard. This paper describes these two criterion-referenced standard-setting procedures as used in this school and related examination performance., Conclusions: Whilst the use of standard-setting procedures goes part way to defining and measuring competence, it is time consuming and requires significant examiner training and acceptance. Using 50% to determine who is and isn't competent is simpler but not transparent, fair nor defensible.

Context: The information explosion and continual changes in the means of accessing information have reinforced the importance of preparing graduates to direct their own learning throughout their careers. Increasingly, medical schools are turning to problem-based curricula to develop in graduates the capacity to 'self-direct' further learning., Problem: Experience shows that, to achieve this goal, there needs to be consistency in interpretation of the goal and faculty-wide agreement about the way the problem-based curriculum fosters self-direction., Suggested Solution: This paper describes the conceptual framework developed by the Graduate School of Medicine, The University of Queensland, to guide the achievement of self-directed, lifelong learning in a graduate entry, problem-based curriculum., Implications: It may be useful for others who are experiencing difficulties with implementing problem-based curricula, and for those who are contemplating changing to problem-based models.

It has been stated that faculty development programmes which are closely linked to particular teaching contexts are most likely to be effective. Over the past 10 years we have developed a model of 'co-teaching' for faculty development which is based upon this premise and which can be applied to any clinical rotation. In this paper we describe our model, in which paired physicians focus on developing their teaching skills while sharing the clinical supervision of residents and medical students. Through iterative phases of teaching, debriefing and planning, co-teachers gain experience in analysing teaching encounters and develop skills in self-evaluation. Teaching occurs in the usual clinical settings such as attending (consultant) teaching rounds, clinic precepting, and case conferences. We discuss our model in the context of educational theory and related literature. We support our positive assessment of the co-teaching model through the precepts of collaborative inquiry and case study methodology. Vignettes, taken from the experiences of the authors, are used to demonstrate how the model is used to develop effective solutions to problems and to help in the maturation of one's skill as an educator. Successful implementation of the model is predicated on the development of a truly collaborative process between co-teachers. We share lessons we have learned from our experience of implementing the model in different clinical venues, such as the contrast between teaching on a hospital ward or in the clinic. This collaborative process has been well received by junior and senior faculty participants in our institution for more than a decade.

Introduction: This paper reports on a teaching strategy designed to support first year undergraduate medical students from non-English speaking backgrounds in a behavioural science course taught at an Australian university., Method: The strategy is described, as is the language profile of students from two successive cohorts who participated in the teaching programme. The effectiveness of the intervention in improving students' academic performance is explored, as gauged by summative assessment and student perceptions., Conclusions: Findings suggest that students disadvantaged by difficulties with language and/or knowledge of Australian culture were able to perform at least as well as other students on a number of summative criteria. Non-English speaking background students perceived the behavioural science course to be difficult, and indicated that they found the teaching support offered to them to be useful. The methodological difficulties and limitations involved in the evaluation of a teaching programme such as this are discussed and the conclusions that can be validly drawn are considered.

Introduction: This paper shows the findings from a survey of 439 senior house officers undertaken as part of the British Medical Association cohort study of 1995 medical graduates. The aim of the study was to assess the quality of senior house officer training in the United Kingdom., Method: In July 1997 a postal questionnaire was sent to a sample of 545 doctors who graduated from medical school in 1995. Responses were received from 515 (95%). Only those doctors who had worked as a senior house officer in the previous 12 months were included in the analysis (n = 439)., Results: Encouraging results are that 69% of the senior house officers surveyed had discussed their progress directly with their consultant, and 24% rated their supervision by their consultant as 'excellent'. Of concern are the findings that 47% of respondents did not receive protected teaching time and 16% were unable to take study leave., Discussion: The study revealed wide variability in the quality of training received by senior house officers in the United Kingdom. Whilst some respondents - notably those in general practice, accident and emergency, paediatrics and psychiatry - had enjoyed a high standard of education and training, it was clear that a minority of posts continue to offer little if any educational value to the post holder. The results point to a need for a more systematic approach to maintaining standards in senior house officer training with greater incentives for under-performing trusts.

Introduction: Induction courses are important to introduce Pre-Registration House Officers (PRHOs) to their new place of work. Traditionally, such programmes employ lectures, small group discussion and demonstrations. They let PRHOs meet members of various hospital disciplines and services. Since 1991, an interactive induction programme has been held each August for new PRHOs in the Eastern Region of Scotland taking up posts in Dundee Teaching Hospitals NHS Trust., Design: Feedback from participants allows the course to be refined each year. In 1995, three paper-based patient management problems (PMPs) were included in the induction programme. Response was favourable. Most of the participants (82%) suggested the PMPs should be used again, but that more time should be allocated to enable them to tackle the problems. By August 1996, we aimed to provide a relevant and interactive programme that encouraged PRHOs to make immediate use of hospital resources. Two PMPs, in print format described likely case histories, with tasks that mirrored the junior doctors' forthcoming responsibilities. Healthcare team members and laboratory staff provided support as did study boards displaying written sheets of relevant clinical information., Results: In the subsequent evaluation, the PMP component was rated highly by participants. They effectively triggered PRHOs to interact with hospital staff., Conclusions: We conclude that PMPs provide a valuable learning experience for junior doctors and are a useful addition to an induction day programme. We plan to refine and increase the use of PMPs in undergraduate and postgraduate settings.

Objectives: The WISDOM project applies Internet technologies to create a virtual classroom in health informatics for primary care professionals. Participants use a facilitated E-mail discussion list supported by a web site which provides on-line resources and an archive of teaching materials., Design: The project took an adult-learning model in which participants identify their learning needs, emphasized using informatics skills in practice, and focused on skills likely to enhance evidence-based practice. The paper describes the project and an evaluation of the first programme which ran in 1997 with 28 participants. Pre- and post-intervention questionnaires were used to assess perceived skills in informatics and evidence-based practice., Setting: University of Sheffield., Subjects: Primary care professionals., Results: Participants reported statistically significant increases in eight informatics skills. There were no significant changes in evidence-based practice skills. The web-site, seminar programme and discussion list were highly rated as useful in delivering informatics training., Conclusions: The WISDOM approach is effective for the delivery of informatics training to primary care professionals, and may be used more widely for other subjects and professional groups. There is a need for further research into facilitating virtual classrooms.

Object: To develop and evaluate the effect of having a personal learning log on Senior House Officers knowledge and confidence., Methods: A multiple choice paper and a confidence checklist for two hospital specialties were developed to assess knowledge and confidence. These were administered to a control group and to an intervention group who had the learning log. Both groups completed an evaluation at the end of the post., Setting: The study took place in Accident & Emergency and Obstetric & Gynaecology posts in Greater Glasgow and Lanarkshire., Subjects: 79 Senior House Officers in Accident & Emergency and 78 Senior House Officers in Obstetrics & Gynaecology., Results: The mean scores in the MCQ and the mode in the confidence checklist increased significantly in both specialties during the post, but there was no significant difference between the control and intervention groups. Forty two learning logs were returned at the end of the study and analysis of these revealed that there was great scope for learning but few documented the specific learning achieved. Evaluation of the posts revealed that some improvements had taken place in teaching and assessment frequency, however, there was scope for further improvement., Conclusion: While the problems of hospital training are well documented, an attempt to improve the situation using a learning log did not have a statistically significant impact on SHO knowledge or confidence. A six-month hospital post appears to present many opportunities for learning but these are not exploited. It is suggested that three things are needed. Firstly, active participation by and personalized feedback from a senior member of staff, with training where needed. Secondly, protected time for tutorials with a planned system of formative assessment, and thirdly, a more positive approach to learning by both SHOs and consultants. Once this occurs, a learning log may have a more significant impact on training.

Objectives: The requirement to align the arrangements for postgraduate training in the United Kingdom with those elsewhere in the European Community provided the opportunity to review and reform our arrangements for higher specialist training. This paper describes the case for change--the strengths and deficiencies of the traditional pattern of postgraduate medical training, demographic influences in the medical workforce and the need for a more structural or planned approach to training., Conclusions: Over the past 5 years substantial progress has been made: the introduction of new regulatory arrangements and a new higher specialist training grade; the development of a managed and flexible system for delivering training to standards set by the Royal Colleges and which can accommodate the needs of those pursuing academic and research medicine; and the opportunity for trainees' progress to be measured against published curricula. The significant programme of change has been underpinned by careful workforce planning and the publication of comprehensive guidance. Significant reform of higher specialist training has been achieved. This paper also makes the case for a more strategic approach to planning and developing medical education across the continuum, from entry to medical school until retirement, which can guide medical education and improve patient care into the next millennium.

Negatively marked multiple-choice questions (MCQs) are part of the assessment process in both the Primary and Final examinations for the fellowship of the Royal College of Anaesthetists. It is said that candidates who guess will lose marks in the MCQ paper. We studied candidates attending a pre-examination revision course and have shown that an evaluation of examination technique is an important part of an individual's preparation. All candidates benefited substantially from backing their educated guesses while only 3 out of 27 lost marks from backing their wild guesses. Failure to appreciate the relationship between knowledge and technique may significantly affect a candidate's performance in the examination.

Assessment within general practice training curricula is necessary to both guide learning and to make certification decisions about competence to practise without supervision in the community, but there is a risk that the two roles could become confused. This paper proposes a conceptual framework that explains the relationship between formative assessment, in-training assessment and end-point assessment, as adopted by the Royal Australian College of General Practitioners Training Programme. The literature is reviewed to suggest assessment formats that could provide a means of making decisions about progress through training without harming the important role of providing feed-back to guide learners.

This paper compares the opportunities for flexible (part-time) specialist training in the UK and elsewhere in the EU in the overall context of the rising numbers of women doctors across Europe. Few other EU countries appear to provide the same opportunities for flexible training as the UK, despite high percentages of women medical students and women medical graduates. There are important differences in training patterns across the EU and some reasons are proposed for why flexible training may be more difficult to implement or may not be required elsewhere in the EU. Reasons include less centralized health care systems and more rigidly structured training programmes. In the context of four main factors affecting medical manpower--medical unemployment, contracted working hours, maternity provisions and duration of training--both the health authorities' need to implement flexible training and the trainee doctors' demand for it would appear to be greater in the UK than in other EU countries.

The development of junior doctors' competence is complex because the hospital environment in which doctors work places many demands on them. The need for quality education and training and personal development may be in direct conflict with the service commitments required from hospitals. This paper describes the methods by which the Postgraduate Medical. Council of New South Wales, Australia, addresses the needs of junior doctors in the state in order to improve the quality of their education. Key elements of the Council's function include the provision of hospital clinical supervisors who oversee junior doctor education and training, and central involvement in supplying the junior doctor workforce to all state hospitals who must meet defined accreditation standards. This paper also provides data on evaluation of those methods and some educational outcomes.

Implicit and explicit in reviews of and changes to vocational education for general practitioners in the 1990s is the challenge to defend the assumption that vocationally trained GPs are better GPs. This paper provides a review of the international literature which has reported on outcomes of general practice vocational training programmes. Through the review we identify both the types of research methodologies used (including a brief discussion of their strengths and limitations) and the outcomes reported of vocational training. Twenty-five studies on the outcomes of vocational training are reviewed. These studies used multiple data sources and one of four methodologies: pre- and post-training comparisons, analysis of learners' or teachers' accounts, audits of general practice or analysis of examination pass rates. When collated, the following range of outcomes from vocational training were identified: improved quality of patient care, increased knowledge, improved general practice skills, increased confidence and desirable GP attitudes and personality traits, increased adherence to practice guidelines and higher examination pass rates. The paper concludes with a summary of research and education issues which arise when we examine the question posed at the outset: are trained GPs better GPs?

The objective of this paper was to investigate what kind of postgraduate education in medical ethics medical residents in Japan receive and what they want for ethical education and guidelines. Sixteen teaching hospitals that provide a general internal medicine residency programme in Japan were used (145 medical residents working at the departments of general internal medicine). A total of 114 residents participated in our survey, yielding a response rate of 79%. Of these, 28% received education in medical ethics more than once a month; 24% were offered it only when ethical problems were involved in actual patient care; and 18% answered that opportunities were very rare and sporadic. A full 30% had received no education in medical ethics at all. Many residents (71%) learned medical ethics from individual supervising doctors. A majority of the residents had been taught about informed consent (79%) and doctor-patient relationships (54%); 46% had learned about the appropriateness of truth telling and of ethical decisions regarding withholding and withdrawing a life-sustaining treatment, respectively. A total of 85 residents (75%) wanted to have more comprehensive education in medical ethics, 13% could not decide, and 12% did not want it. Many (66%) thought that both doctors and ethical philosophers should jointly teach medical ethics in postgraduate residency programmes. The results suggest that many residents desire more comprehensive and interdisciplinary education in medical ethics and educators in Japan should aim to develop education programmes to meet these desires.

A structured trainer's report for use in summative assessment in general practice has been designed, and it is important that the content validity of this report is tested before it is widely adopted. The aim of this paper was to assess the content validity of a proposed report from the perspective of doctors who have recently completed vocational training. A postal questionnaire survey was sent out seeking the views of 220 doctors who had completed vocational training in 1994 as to whether or not the proposed contents were items that are needed in general practice, and whether or not the items were suitable for assessment by means of a trainer's report. The response rate was 73.3%. More than 85% of respondents agreed that the 31 items proposed for inclusion in the trainer's report were needed in general practice. While the proportions agreeing that the items were suitable for assessment by a trainer's report were considerably lower, for 26 items significantly more agreed that they were suitable than disagreed. Analysis of the freetext comments made by respondents illustrated their concerns. The results provide support for the content validity of this proposed trainer's report; however it is important that the concerns expressed are addressed.

Aims: To determine the content of a distance learning course in therapeutics for general practitioners (GPs)., Methods: This paper reports the results of a three-round Delphi study. The respondent group comprised 21 GPs who were expert in their field. In the first round, the experts were interviewed to determine the knowledge, skills, competencies and attitudes required by GPs to prescribe effectively; the justification for, and scope of a distance learning course; and the preferred learning methods, format and methods of assessment. The first round generated 251 statements, which were collapsed into 108 statements covering thirteen domains. In the second and third rounds, a questionnaire was posted to the GPs. 95% responded to the second round questionnaire and agreed upon 86 statements, which were then collated into four domains. In the third round, 19 GPs rated each of the 86 statements on a five point scale. Consensus was reached for 99% of statements: 40 on the aims, design, format, organization and assessment of the course; and 45 on the knowledge and skills to be acquired by GPs who complete the course., Results: The results revealed a consensus in favour of: modules at regular intervals some flexibility in meeting deadlines interaction among students for mutual support easy access to course tutors some face-to-face contact to complement distance learning material clear guidance on effective and safe prescribing emphasis on importance of 'people skills', Conclusions: The Delphi process can be used to determine the competencies required for continuing medical education in therapeutics.

A series of questionnaires was used to determine the amount of formative assessment going on within the est of Scotland Region of the UK and its perceived value by trainees (General Practice [GP] Registrars) both at the beginning and end of training. The first survey was carried out in 1989 and the second in 1994. Trainers and course organizers were surveyed in 1994 to determine their attitudes to the use of videotaped consultations for formative assessment. In 1991, the region had initiated a mandatory formative assessment programme which included regular use of videotaped consultations, confidence rating scales and Manchester ratings (RCGP Occasional Paper Number 40). The use of a range of assessment methods for formative assessment of GP Registrars increased considerably between 1989 and 1994. The percentage of trainees using videotaped consultation analysis increased from 76 to 94%, for Manchester ratings from 52 to 68% and for confidence rating scales from 63 to 74%. Video and confidence scales were rated highly by trainees who were assessed by them and by most trainees at the start of the year, but less highly by those who had not been assessed by them by the end of the trainee year. Manchester ratings were not thought to be as useful, and for these there was no difference between users and non-users. Despite the mandatory system, a significant number of trainees (76%) were still not receiving the minimum assessment stipulated. Trainers rated lack of time as the main limiting factor to the greater use of video. We conclude that trainees who are exposed to assessment methods, particularly video, find it useful, but that some trainees are still receiving less than is optimal. We propose increased trainer education and intensified monitoring of the assessment carried out in training Practices.

This paper sets out some of the issues relating to certification of specialists. It first defines the purpose of certification as assuring the public of the level of competence of specialist practice. It then describes some of the issues involved, which include the assessment of competence, the need for public involvement, the issue of re-certification, and the problem of dealing with poor doctors. It concludes with a challenge to doctors to seize the opportunities and to enhance the quality of teaching and research in medical education.

This paper describes the design and initial testing of the ACCESS (Anaesthetic Computer Controlled Emergency Situation Simulator) system, which has been designed to simulate anaesthetic emergencies with the aim of providing training for junior doctors. The simulations require little or no capital expenditure with minimal use of time by staff or trainees. They are based on standard anaesthetic equipment, with a microcomputer providing an image of commonly used instruments. Problems are presented as scenarios administered by the teacher, and test the skills of the pupil. During 64 scenarios, five trainees caused two 'deaths' and solved the problems in a median time of 2.5 min, while an experienced group of anaesthetists caused one 'death' and took 1.8 min. The simulation was rated by the pupils as easy to use, realistic and a valuable educational tool.

Luck plays some role in passing any examination. When candidates pass a postgraduate examination at the second, third or subsequent attempt is it because their knowledge has truly improved or because they have at least been lucky? In this paper a simple model, requiring knowledge only of the pass rates at resits, and of the reliability of the examination, is applied to the MRCGP examination of the Royal College of General Practitioners. Candidates increase their true ability before second and third attempts at the examination, after which ability declines.

Kuwait has a comprehensive and well-structured health care system. However, to deliver such care the country relies on expatriate medical doctors. This paper attempts to discuss the sociocultural influences on the training of Kuwaiti medical doctors and their specialty choices in order to gauge future requirements of the Kuwaiti Health Services.

This paper describes a programme of curriculum development in an Indonesian post-graduate Faculty of Public Health. This faculty redefined all its curricula with a 2-year period, and these curricula are now stated in terms of sets of instructional objectives which are skill-based and learner-centered. These curricula are now being implemented in ways which are consistent with contemporary educational thinking. It is contended that the rapidity with which these changes occurred can be accounted for in terms of: (a) the strong support of the faculty's leadership; (b) the methods used to bring about these changes; and (c) the sustained efforts made by many of the teaching staff.